Nutrition Essentials for Nursing Practice-2014-CD

Susan G. Dudek, RD, CDN, BSNutrition Instructor, Dietetic Technology ProgramErie Community CollegeWilliamsville, New York

Consultant Dietitian for Employee AssistanceProgram of Child and Family ServicesWilliamsville, New York

S E V E N T H E D I T I O N

Nutrition Essentials for Nursing Practice

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66485457-66485438 www.ketabpezeshki.com

Acquisitions Editor: David TroyProduct Manager: Maria McAveyProduction Project Manager: Marian BellusEditorial Assistant: Latisha Ogelsby Design Coordinator: Holly Reid McLaughlinCreative Services Director: Doug SmockManufacturing Coordinator: Karin Duffi eldPrepress Vendor: Absolute Services, Inc.

Seventh Edition

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Copyright 2010, 2007, 2006, 2001 by Lippincott Williams and Wilkins. Copyright 1997 by Lippincott- Raven Publish-ers. Copyright 1993, 1987 by J. B. Lippincott Company. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by in-dividuals as part of their offi cial duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Lippincott Williams & Wilkins at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at [email protected], or via our website at lww.com (products and services).

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Library of Congress Cataloging-in-Publication Data

Dudek, Susan G. Nutrition essentials for nursing practice / Susan G. Dudek. 7th ed. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4511-8612-3 (alk. paper) I. Title. [DNLM: 1. Diet TherapyHandbooks. 2. Diet TherapyNurses Instruction. 3. Nutritional Physiological Phenomena Handbooks. 4. Nutritional Physiological PhenomenaNurses Instruction. WB 39] RM216 615.8'54dc23

2013007075

Care has been taken to confi rm the accuracy of the information presented and to describe generally accepted practices. How-ever, the author, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations.

The author, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant fl ow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug.

Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in his or her clinical practice.

LWW.com

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In loving memory of my mother, Annie M. Maedl

everyone should be so lucky to have a mom like her.

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iv

Reviewers

Zita Allen, RN, MSNProfessor of NursingAlverno CollegeMilwaukee, Wisconsin

Carmen Bruni, MSN, RN, CANAssistant ProfessorTexas A&M International UniversityLaredo, Texas

Ann Cleary, DNS, RN, NP-CAssociate Professor of NursingLong Island University, Brooklyn CampusBrooklyn, New York

Tammie Cohen, RN, BSNursing Instructor, Faculty Advisory Committee

ChairpersonWestern Suffolk BOCESNorthport, New York

Janet Goeldner, MSNProfessorUniversity of CincinnatiRaymond Walters CollegeCincinnati, Ohio

Coleen Kumar, RN, MSNAssociate Professor NursingDepartment Deputy ChairpersonKingsborough Community CollegeBrooklyn, New York

Karen Lincoln, RNC, MSNNursing FacultyMontcalm Community CollegeSidney, Michigan

Carol Isaac MacKusick, PhDc, MSN, RN, CNNAdjunct FacultyClayton State UniversityMorrow, Georgia

Marina Martinez-Kratz, RN, BSN, MSProfessor of NursingJackson Community CollegeJackson, Michigan

Janet Tompkins McMahon, RN, MSNClinical Associate Professor of NursingTowson UniversityTowson, Maryland

Patricia J. Neafsey, RD, PhDProfessorUniversity of Connecticut School of NursingStorrs, Connecticut

Cheryl L. Neudauer, PhD, MEdBiology FacultyCenter for Teaching and Learning Campus LeaderMinneapolis Community and Technical CollegeMinneapolis, Minnesota

Christine M. Prince, RN, BSN, CCMNursing FacultyBrown Mackie College IndianapolisIndianapolis, Indiana

Rhonda Savain, RN, MSNNursing InstructorReady to Pass Inc.West Hempstead, New York

Nancy West, RN, MNProfessor of NursingJohnson County Community CollegeOverland Park, Kansas

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vL ike air and sleep, nutrition is a basic human need essential for survival. Nutrition provides energy and vitality, helps reduce the risk of chronic disease, and can aid in recovery. It is a dynamic blend of science and art, evolving over time and in response to technological advances and cultural shifts. Nutrition at its most basic level is foodfor the mind, body, and soul.

Although considered the realm of the dietitian, nutrition is a vital and integral compo-nent of nursing care. Todays nurses need to know, understand, apply, analyze, synthesize, and evaluate nutrition throughout the life cycle and along the wellness/illness continuum. They incorporate nutrition into all aspects of nursing care plans, from assessment and nursing diagnoses to implementation and evaluation. By virtue of their close contact with patients and families, nurses are often on the front line in facilitating nutrition. This text seeks to give student nurses a practical and valuable nutrition foundation to better serve themselves and their clients.

NEW TO THIS EDITION

This seventh edition continues the approach of providing the essential information nurses need to know for practice. Building upon this framework, content has been thoroughly updated to refl ect the latest evidence-based practice. Examples of content updates that are new to this edition are as follows:

MyPlate, which replaces MyPyramid as the graphic to illustrate the Dietary Guidelines for Americans

Recommended Dietary Allowances (RDAs) for calcium and vitamin D Inclusion of a validated stand-alone nutrition screening tool for older adults that is ap-

propriate for community settings and in clinical practice Expanded coverage of bariatric surgery and obesity in general, particularly with regard

to the importance of behavioral strategies for navigating our increasingly obesogenic environment

The low-FODMAP (fermental oligo-, di-, and monosaccharides and polyols) diet for irritable bowel syndrome and possibly other gastrointestinal disorders

A shift in focus from single nutrients (e.g., saturated fat) to a food pattern approach (e.g., the DASH diet) for communicating and implementing a heart healthy diet

Updated 2011 nutrition therapy guidelines for patients with chronic kidney disease who are not on dialysis

ORGANIZATION OF THE TEXT

Unit One is devoted to Principles of Nutrition. It begins with Chapter 1, Nutrition in Nursing, which focuses on why and how nutrition is important to nurses in all settings. Chapters devoted to carbohydrates, protein, lipids, vitamins, water and minerals, and energy balance provide a foundation for wellness. The second part of each chapter highlights health promotion topics and demonstrates practical application of essential information, such as how to increase fi ber intake, criteria to consider when buying a vitamin supplement, and the risks and benefi ts of a vegetarian diet.

Preface

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vi P R E F A C E

Unit Two, Nutrition in Health Promotion, begins with Chapter 8, Guidelines for Healthy Eating. This chapter features the Dietary Reference Intakes, the Dietary Guide-lines for Americans, and MyPlate. Other chapters in this unit examine consumer issues and cultural and religious infl uences on food and nutrition. The nutritional needs associated with the life cycle are presented in chapters devoted to pregnant and lactating women, chil-dren and adolescents, and older adults.

Unit Three, Nutrition in Clinical Practice, includes nutrition therapy for obesity and eating disorders, enteral and parenteral nutrition, metabolic and respiratory stress, gastro-intestinal disorders, diabetes, cardiovascular disorders, renal disorders, cancer, and HIV/AIDS. Pathophysiology is tightly focused as it pertains to nutrition.

RECURRING FEATURES

This edition retains popular features of the previous edition to facilitate learning and engage students.

Check Your Knowledge presents true/false questions at the beginning of each chapter to assess the students baseline knowledge. Questions relate to chapter Learning Objectives.

Key Terms are defined in the margin for convenient reference. Quick Bitesfewer and more condensed to improve layout and readability in the new

editionprovide quick nutrition facts, valuable information, and current research. Nursing Process tables clearly present sample application of nutrition concepts in con-

text of the nursing process. How Do You Respond? helps students identify potential questions they may encounter

in the clinical setting and prepares them to think on their feet. A Case Study and Study Questions at the end of each chapter challenge students to

apply what they have learned. Key Concepts summarize important information from each chapter.

TEACHING AND LEARNING RESOURCES

Instructors and students will fi nd valuable resources to accompany the book on at http://thePoint.lww.com/Dudek7e.

Resources for InstructorsComprehensive teaching resources are available to instructors upon adoption of this text and include the following materials.

A free E-book on thePoint provides access to the books full text and images online. A Test Generator lets instructors put together exclusive new tests from a bank contain-

ing NCLEX-style questions. PowerPoint Presentations provide an easy way to integrate the textbook with the class-

room. Multiple-choice and true/false questions are included to promote class participation. An Image Bank provides the photographs and illustrations from this text for use in

course materials. Access to all student resources is also provided.

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P R E F A C E vii

Resources for StudentsStudents can activate the code in the front of this book at http://thePoint.lww.com/activate to access the following free resources.

A free E-book on thePoint provides access to the books full text and images online. NEW! Practice & Learn Interactive Case Studies provide realistic case examples and

offer students the opportunity to apply nutrition essentials to nursing care. Journal Articles provided for each chapter offer access to current research available in

Lippincott Williams & Wilkins journals.

I hope this text and teaching/learning resource package provide the impetus to embrace nutrition on both a personal and professional level.

Susan G. Dudek, RD, CDN, BS

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viii

I am humbled and grateful to be still writing this book after six editions. It is a project that has been professionally rewarding, personally challenging, and rich with opportunities to grow. In large part, the success of this book rests with the dedicated and creative profes-sionals at Lippincott Williams & Wilkins. Because of their support and talents, I am able to do what I lovewrite, create, teach, and learn. I especially thank

David Troy, Senior Acquisitions Editor, who provided the spark to ignite the project. Maria McAvey, Editorial Product Manager, for her meticulous attention to detail and

gentle guidance. Marian Bellus, Production Project Manager; Holly Reid McLaughlin, Design Coordinator;

John Johnson, Education Marketing Manager, Nursing; and Latisha Ogelsby, Editorial Assistant, the behind-the-scene professionals whose efforts help transform an ugly duck-ling into a beautiful swan.

The reviewers of the sixth edition, whose insightful comments and suggestions helped shape a new and improved edition.

My friends and familymy sideline cheerleaderswho so patiently gave me the time and space to work on my story.

I am especially thankful to my husband Joe . . . always there through thick and thin.

Acknowledgments

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ix

U N I T O N E Principles of Nutrition 1

CHAPTER 1 Nutrition in Nursing 2CHAPTER 2 Carbohydrates 18CHAPTER 3 Protein 46CHAPTER 4 Lipids 66CHAPTER 5 Vitamins 92CHAPTER 6 Water and Minerals 124CHAPTER 7 Energy Balance 156

U N I T T W O Nutrition in Health Promotion 177

CHAPTER 8 Guidelines for Healthy Eating 178CHAPTER 9 Consumer Issues 200CHAPTER 10 Cultural and Religious Infl uences on Food and Nutrition 230CHAPTER 11 Healthy Eating for Healthy Babies 257CHAPTER 12 Nutrition for Infants, Children, and Adolescents 286CHAPTER 13 Nutrition for Older Adults 320

U N I T T H R E E Nutrition in Clinical Practice 353

CHAPTER 14 Obesity and Eating Disorders 354CHAPTER 15 Feeding Patients: Oral Diets and Enteral and Parenteral Nutrition 393CHAPTER 16 Nutrition for Patients with Metabolic or Respiratory Stress 423CHAPTER 17 Nutrition for Patients with Upper Gastrointestinal Disorders 443CHAPTER 18 Nutrition for Patients with Disorders of the Lower GI Tract and

Accessory Organs 461CHAPTER 19 Nutrition for Patients with Diabetes Mellitus 497CHAPTER 20 Nutrition for Patients with Cardiovascular Disorders 535CHAPTER 21 Nutrition for Patients with Kidney Disorders 567CHAPTER 22 Nutrition for Patients with Cancer or HIV/AIDS 593

A P P E N D I C E S

APPENDIX 1 Dietary Reference Intakes (DRIs): Recommended Dietary Allowances and Adequate Intakes, Total Water and Macronutrients 624

APPENDIX 2 Dietary Reference Intakes (DRIs): Recommended Dietary Allowances and Adequate Intakes, Vitamins 625

APPENDIX 3 Dietary Reference Intakes (DRIs): Recommended Dietary Allowances and Adequate Intakes, Elements 628

APPENDIX 4 Answers to Study Questions 630

INDEX 633

Contents

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U N I T O N E

Principles of Nutrition

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2C H E C K Y O U R K N O W L E D G E

Nutrition in Nursing1TRUE FALSE

1 The nurses role in nutrition is to call the dietitian.

2 Nutrition screening is used to identify clients at risk for malnutrition.

3 The Joint Commission stipulates the criteria to be included on a nutritional screen for hospitalized patients.

4 Changes in weight refl ect acute changes in nutritional status.

5 A person can be malnourished without being underweight.

6 The only cause of a low serum albumin concentration is protein malnutrition.

7 Signifi cant weight loss is 5% of body weight in 1 month.

8 People who take fi ve or more prescription or over-the-counter medications or dietary supplements are at risk for nutritional problems.

9 Obtaining reliable and accurate information on what the client usually eats can help identify intake as a source of nutrition problems.

10 Physical signs and symptoms of malnutrition develop only after other signs of malnutri-tion are apparent (e.g., abnormal lab values, weight change).

U p o n c o m p l e t i o n o f t h i s c h a p t e r, y o u w i l l b e a b l e t o

1 Compare nutrition screening to nutrition assessment.2 Evaluate weight loss for its signifi cance over a 1-month or 6-month interval.3 Discuss the validity and reliability of using physical signs to support a nutritional diagnosis

of malnutrition.4 Give examples of nursing diagnoses that may use nutrition therapy as an intervention.5 Demonstrate how nurses can facilitate client and family teaching of nutrition therapy.6 Explain why an alternative term to diet is useful.

L E A R N I N G O B J E C T I V E S



C H A P T E R 1 Nutrition in Nursing 3

Based on Maslows hierarchy of needs, food and nutrition rank on the same level as air in the basic necessities of life. Obviously, death eventually occurs without food. But unlike air, food does so much more than simply sustain life. Food is loaded with personal, social, and cultural meanings that defi ne our food values, beliefs, and customs. That food nour-ishes the mind as well as the body broadens nutrition to an art as well as a science. Nutrition is not simply a matter of food or no food but rather a question of what kind, how much, how often, and why. Merging want with need and pleasure with health are keys to feeding the body, mind, and soul.

Although the dietitian is the nutrition and food expert, nurses play a vital role in nutri-tion care. Nurses may be responsible for screening hospitalized patients to identify patients at nutritional risk. They often serve as the liaison between the dietitian and physician as well as with other members of the health-care team. Nurses have far more contact with the patient and family and are often available as a nutrition resource when dietitians are not, such as during the evening, on weekends, and during discharge instructions. In home care and wellness settings, dietitians may be available only on a consultative basis. Nurses may reinforce nutrition counseling provided by the dietitian and may be responsible for basic nutrition education in hospitalized clients with low to mild nutritional risk. Nurses are inti-mately involved in all aspects of nutritional care.

This chapter discusses nutrition within the context of nursing, including nutrition screening and how nutrition can be integrated into the nursing care process.

NUTRITION SCREENING

Nutrition screening is a quick look at a few variables to identify individuals who are mal-nourished or who are at risk for malnutrition so that an in-depth nutrition assessment can follow. Screening tools should be simple, reliable, valid, applicable to most patients or clients in the group, and use data that is readily available (Academy of Nutrition and Dietetics, 2012). For instance, a community-based senior center may use a nutrition screen that focuses mostly on intake risks common to that population, such as whether the client eats alone most of the time and/or has physical limitations that impair the abil-ity to buy or cook food (Fig. 1.1). In contrast, common screening parameters in acute care settings include unintentional weight loss, appetite, body mass index (BMI), and disease severity. Advanced age, dementia, and other factors may be considered. There is no universally agreed upon tool that is valid and reliable at identifying risk of malnutrition in all populations at all times.

The Joint Commission, a nonprofi t organization that sets health-care standards and accredits health-care facilities that meet those standards, specifi es that nutrition screening be conducted within 24 hours after admission to a hospital or other health-care facilityeven on weekends and holidays. The Joint Commission allows facilities to determine screening criteria and how risk is defi ned. For instance, a hospital may use serum creatinine level as a screening criterion, with a level greater than 2.5 mg/dL defi ned as high risk because the majority of their patients are elderly and the prevalence of chronic renal problems is high. The Joint Commission also leaves the decision of who performs the screening up to indi-vidual facilities. Because the standard applies 24 hours a day, 7 days a week, staff nurses are often responsible for completing the screen as part of the admission process. Clients who pass the initial screen are rescreened after a specifi ed amount of time to determine if their status has changed.

Nutritional Screen: a quick look at a few variables to judge a clients relative risk for nutritional problems. Can be custom de-signed for a particular population (e.g., preg-nant women) or for a specific disorder (e.g., cardiac disease).Malnutrition: literally bad nutrition or any nutritional imbalance including overnutrition. In practice, malnutrition usually means undernu-trition or an inadequate intake of protein and/or calories that causes loss of fat stores and/or muscle wasting.



4 U N I T 1 Principles of Nutrition

NUTRITION CARE PROCESS

Clients considered to be at moderate or high risk for malnutrition through screening are usually referred to a dietitian for a comprehensive nutritional assessment to identify spe-cifi c risks or confi rm the existence of malnutrition. Nutritional assessment is more accu-rately called the nutrition care process, which includes four steps (Fig. 1.2). While nurses use the same problem-solving model to develop nursing or multidisciplinary care plans that

I have an illness or condition that made me change the kind and/or amount of food I eat.

I eat fewer than two meals per day.

I eat few fruits or vegetables, or milk products.

I have three or more drinks of beer, liquor or wine almost every day.

I have tooth or mouth problems that make it hard for me to eat.

I don't always have enough money to buy the food I need.

I eat alone most of the time.

I take three or more different prescribed or over-the-counter drugs a day.

Without wanting to, I have lost or gained 10 pounds in the last six months.

I am not always physically able to shop, cook and/or feed myself.

TOTAL

YES

2

3

2

2

2

4

1

1

2

2

Total your nutritional score. If its

Remember that warning signs suggest risk, but do not represent diagnosis of any condition.

Good! Recheck your nutritional score in six months.

You are at moderate nutritional risk. See what can be done to improve your eating habits and lifestyle. Your office on aging, senior nutrition program, senior citizens center or health department can help. Recheck your nutritional score in three months.

You are at high nutritional risk. Bring this checklist the next time you see your doctor, dietitian or other qualified health or social service professional. Talk with them about any problems you may have. Ask for help to improve your nutritional health.

0-2

3-5

6 or more

DETERMINE YOUR NUTRITIONAL HEALTH

The warning signs of poor nutritional health are often overlooked. Use this checklist to find out if you or someone you know is at nutritional risk.

Read the statements below. Circle the number in the yes column for those that apply to you or someone you know. For each yes answer, score the number in the box. Total your nutritional score.

F I G U R E 1 . 1 Determine your nutritional health. American Academy of Family Physicians, the American Dietetic Association, the National Council on the Aging, Inc. The Nutrition Screening Initiative.

Nutritional Assessment: an in-depth analysis of a persons nutritional status. In the clinical setting, nutritional assessments focus on moderate- to high-risk patients with suspected or confirmed proteinenergy malnutrition.




may also integrate nutrition, the nutritional plan of care devised by dietitians is specifi c for nutrition problems. Some obvious differences in focus are described below:

Dietitians may obtain much of their preliminary information about the patient from the nursing history and physical examination, such as height and weight; skin integrity; usual diet prior to admission; difficulty chewing, swallowing, or self-feeding; chief com-plaint; medications, supplements, and over-the-counter drugs used prior to admission; and living situation. Dietitians may request laboratory tests to assess vitamin levels when micronutrient deficiencies are suspected.

Dietitians interview patients and/or families to obtain a nutrition history, which may include information on current dietary habits; recent changes in intake or appetite; intake of snacks; alcohol consumption; food allergies and intolerances; ethnic, cultural, or religious diet influ-ences; nutrition knowledge and beliefs; and use of supplements. A nutrition history can help differentiate nutrition problems caused by inadequate intake from those caused by disease.

Dietitians usually calculate estimated calorie and protein requirements based on the assessment data and determine whether the diet ordered is adequate and appropriate for the individual.

Dietitians determine nutrition diagnoses that define the nutritional problem, etiology, and signs and symptoms. While a nursing diagnosis statement may begin with Altered nutrition: eating less than the body needs, a nutrition diagnosis would be more specific, such as Inadequate proteinenergy intake.

Dietitians may also determine the appropriate malnutrition diagnosis code for the patient for hospital reimbursement purposes.

Nutrition interventions may include requesting a diet order change, requesting additional laboratory tests to monitor nutritional repletion, and performing nutrition counseling or education.

Screening

Nutritionassessment

Nutritiondiagnosis

Nutritionintervention

Nutrition monitoringand evaluation

F I G U R E 1 . 2 The nutrition care process. Like the nursing process, the nutrition care process is a problem-solving method used to evaluate and treat nutrition-related problems.




NUTRITION IN THE NURSING PROCESS

In nursing care plans, nutrition may be part of the assessment data, diagnosis, plan, implementation, or evaluation. The remainder of this chapter is intended to help nurses provide quality nursing care that includes basic nutrition, not to help nurses become dietitians.

AssessmentIt is well recognized that malnutrition is a major contributor to morbidity, mortality, im-paired quality of life, and prolonged hospital stays (White et al., 2012). However, there is currently no single, universally agreed upon method to assess or diagnose malnutrition. Approaches vary widely and may lack sensitivity (the ability to diagnose all people who are malnourished) and specifi city (misdiagnosing a well-nourished person). For instance, albumin and prealbumin have been used as diagnostic markers of malnutrition. These pro-teins are now known to be negative acute phase proteins, which means their levels de-crease in response to infl ammation and physiologic stress. Because they are not specifi c for nutritional status, failure of these levels to increase with nutrition repletion does not mean that nutrition therapy is inadequate (Fessler, 2008). Although their usefulness in diagnosing malnutrition is limited, these proteins may help identify patients at high risk for morbidity, mortality, and malnutrition (Banh, 2006). BMI and some or all of the compo-nents of a subjective global assessment (Box 1.1) are commonly used to assess nutrition (Fessler, 2008).

Medical History and Diagnosis

The chief complaint and medical history may reveal disease-related risks for malnutrition and whether infl ammation is present (Fig. 1.3). Patients with gastrointestinal symptoms or disorders are among those who are most prone to malnutrition, particularly when symptoms such as nausea, vomiting, diarrhea, and anorexia last for more than 2 weeks. Box 1.2 lists psychosocial factors that may impact intake or requirements and help identify nutrition counseling needs.

Subjective Global Assessment (SGA): a clinical method of assessing nutritional status based on findings in a health history and physical examination.

Weight Change Unintentional weight loss and the time

period of loss

Dietary Intake Change from normal, duration, type of

diet consumed

Gastrointestinal Symptoms Lasting Longer than 2 Weeks Nausea, vomiting, diarrhea, anorexia

Functional Capacity Normal or suboptimal; ambulatory or

bedridden

Disease and Its Relation to Nutritional Requirements Primary diagnosis; severity of metabolic

stress

Physical Signs and Severity of Findings Loss of subcutaneous fat (triceps, chest),

muscle wasting (quadriceps, deltoids), ankle edema, sacral edema, ascites

CRITERIA INCLUDED IN SUBJECTIVE GLOBAL ASSESSMENTBox 1.1




Psychological Factors Depression Eating disorders Psychosis

Social Factors Illiteracy Language barriers Limited knowledge of nutrition and food

safety Altered or impaired intake related to

culture Altered or impaired intake related to

religion

Lack of caregiver or social support system

Social isolation Lack of or inadequate cooking

arrangements Limited or low income Limited access to transportation to

obtain food Advanced age (older than 80 years) Lack of or extreme physical activity Use of tobacco or recreational drugs Limited use or knowledge of community

resources

PSYCHOSOCIAL FACTORS THAT MAY INFLUENCE INTAKE, NUTRITIONAL REQUIREMENTS, OR NUTRITION COUNSELINGBox 1.2

Acute illness(e.g., infection,

trauma, pancreatitis)Inflammation/

catabolismFrequent infection,altered GI function

Malnutrition

Inadequate intake/nutrient availability

(anorexia, malabsorption)

Chronic illness(e.g., cancer, AIDS, COPD)

F I G U R E 1 . 3 Factors that may be involved in the etiology of illness-related malnutrition.

Body Mass Index

Body mass index (BMI) is an index of a persons weight in relation to height used to estimate relative risk of health problems related to weight. Because it is relatively quick and easy to measure height and weight and requires little skill, actual measures, not estimates, should be used whenever possible to ensure accuracy and reliability. A patients stated height and weight should be used only when there are no other options.

Body Mass Index: an index of weight in relation to height that is calculated mathemat-ically by dividing weight in kilograms by the square of height in meters.

Q U I C K B I T E

Interpreting BMI

18.5 underweight18.524.9 healthy weight2529.9 overweight3034.9 obesity class 13539.9 obesity class 240 obesity class 3




Healthy or normal BMI is defi ned numerically as 18.5 to 24.9. Values above and below this range are associated with increased health risks. Although BMI can be calcu-lated with a mathematical formula, tables and nomograms are available for convenience (see Chapter 14). One drawback of using BMI is that a person can have a high BMI and still be undernourished in one or more nutrients if intake is unbalanced or if nutritional needs are high and intake is inadequate.

Weight Change

Unintentional weight loss is a well-validated indicator of malnutrition (White et al., 2012). The signifi cance of weight change is evaluated after the percentage of usual body weight lost in a given period of time is calculated (Box 1.3). Usually, weight changes are more refl ective of chronic, not acute, changes in nutritional status. The patients weight can be unreliable or invalid due to hydration status. Edema, anasarca, fl uid resuscitation, heart failure, and chronic liver or renal disease can falsely infl ate weight.

Dietary Intake

A decrease in intake compared to the patients normal intake may indicate nutritional risk. However, like other data, validity and reliability may be an issue. Although the nurse may only be required to fi ll in a blank space next to the word appetite, simply ask-ing the client How is your appetite? will probably not provide suffi cient information. A better question may be Has the type or amount of food you eat recently changed? If so, please explain. Consuming only liquids and severely limiting the type or amount of food are risks.

Another question to avoid while obtaining a nursing history is Are you on a diet? To many people, diet is synonymous with weight loss diet; they may fail to mention they use nutrition therapy to avoid sodium, modify fat, or count carbohydrates. A better question would be, Do you avoid any particular foods? or Do you watch what you eat in any way? Even the term meal may elicit a stereotypical mental picture. Questions to consider when asking a client about his or her usual intake appear in Box 1.4.

Calculating Percent Weight Change

% weight change (usual body weight current body weight)

_____ usual body weight

100

Signifi cant Unintentional Weight Loss

Time Period (% of Weight Lost)

1 week 21 month 53 months 7.56 months 10

Source: Academy of Nutrition and Dietetics. (2012). Nutrition Care Manual. Available at http://nutritioncaremanual.org/content.cfm?ncm_content_id=79554. Accessed on 8/16/2012.

CALCULATING AND EVALUATING PERCENT WEIGHT CHANGEBox 1.3




How many meals and snacks do you eat in a 24-hour period? This question helps to establish the pattern of eating and identifi es unusual food habits such as pica, food faddism, eating disorders, and meal skipping.

Do you have any food allergies or intolerances, and, if so, what are they? The greater the number of foods restricted or eliminated in the diet, the greater the likelihood of nutri-tional defi ciencies. This question may also shed light on the clients need for nutrition counseling. For instance, clients with hiatal hernia who are intolerant of citrus fruits and juices may benefi t from counseling on how to ensure an adequate intake of vitamin C.

What types of vitamin, mineral, herbal, or other supplements do you use and why? A multivitamin, multimineral supplement that provides 100% or less of the daily value offers some protection against less than optimal food choices. Folic acid in supplements or fortifi ed food is recommended for women of childbearing age; people older than 50 years are encouraged to obtain vitamin B12 from fortifi ed foods or supplements. However, potential problems may arise from other types or amounts of supplements. For instance, large doses of vitamins A, B6, and D have the potential to cause toxicity symptoms. Iron supplements may decrease zinc absorption and negatively impact zinc status over time.

What concerns do you have about what or how you eat? This question places the responsibility of healthy eating with the client, where it should be. A client who may benefi t from nutrition intervention and counseling in theory may not be a candidate for such in practice depending on his or her level of interest and motivation. This question may also shed light on whether or not the client understands what he or she should be eating and whether the client is willing to make changes in eating habits.

For clients who are acutely ill: How has illness affected your choice or tolerance of food? Sometimes, food aversions or intolerances can shed light on what is going on with the client. For instance, someone who experiences abdominal pain that is relieved by eating may have a duodenal ulcer. Clients with little or no intake of food or liquids are at risk for dehydration and nutrient defi ciencies.

Who prepares the meals? This person may need nutritional counseling.Do you have enough food to eat? Be aware that pride and an unwillingness to admit inabil-

ity to afford an adequate diet may prevent some clients and families from answering this question. For hospitalized clients, it may be more useful to ask the client to compare the size of the meals they are served in the hospital with the size of meals they normally eat.

How much alcohol do you consume daily? Risk begins at more than one drink daily for women and more than two drinks daily for men.

QUESTIONS TO CONSIDER ABOUT INTAKEBox 1.4

Physical Findings

Loss of subcutaneous fat, such as in the triceps and chest, muscle wasting in the quadriceps and deltoids, ankle edema, sacral edema, and ascites may be indicative of malnutrition. These abnormal fi ndings are subjectively assessed as mild, moderate, or severe.

Box 1.5 lists other physical fi ndings that may suggest malnutrition. Most physical symp-toms cannot be considered diagnostic because evaluation of normal versus abnormal fi ndings is subjective, and the signs of malnutrition may be nonspecifi c. For instance, dull, dry hair may be related to severe protein defi ciency or to overexposure to the sun or use of hair products such as colorants. In addition, physical signs and symptoms of malnutri-tion can vary in intensity among population groups because of genetic and environmental differences. Lastly, physical fi ndings occur only with overt malnutrition, not subclinicalmalnutrition.

Subclinical: asymptomatic.




Nursing DiagnosisA diagnosis is made after assessment data are interpreted. Nursing diagnoses in hospitals and long-term care facilities provide written documentation of the clients status and serve as a framework for the plan of care that follows. The diagnoses relate directly to nutrition when the pattern of nutrition and metabolism is the problem. Other nursing diagnoses, while not specifi c for nutrition, may involve nutrition as part of the plan, such as teaching the patient how to increase fi ber intake to relieve the nursing diagnosis of constipation. Box 1.6 lists nursing diagnoses with nutritional signifi cance.

Planning: Client OutcomesOutcomes, or goals, should be measurable, attainable, specifi c, and client centered. How do you measure success against a vague goal of gain weight by eating better? Is eating better achieved by adding butter to foods to increase calories or by substituting 1% milk for whole milk because it is heart healthy? Is a 1-pound weight gain in 1 month acceptable or is 1 pound/week preferable? Is 1 pound/week attainable if the client has accelerated metabolism and catabolism caused by third-degree burns?

Client-centered outcomes place the focus on the client, not the health-care provider; they specify where the client is heading. Whenever possible, give the client the opportunity to actively participate in goal setting, even if the clients perception of need differs from yours. In matters that do not involve life or death, it is best to fi rst address the clients con-cerns. Your primary consideration may be the patients signifi cant weight loss during the last 6 months of chemotherapy, whereas the patients major concern may be fatigue. The two issues are undoubtedly related, but your effectiveness as a change agent is greater if you approach the problem from the clients perspective. Commitment to achieving the goal is greatly increased when the client owns the goal.

Keep in mind that the goal for all clients is to consume adequate calories, protein, and nutrients using foods they like and tolerate as appropriate. If possible, additional short-term goals may be set to alleviate symptoms or side effects of disease or treatments and to prevent complications or recurrences if appropriate. After short-term goals are met, attention can expand to promoting healthy eating to reduce the risk of chronic diet-related diseases such as obesity, diabetes, hypertension, and atherosclerosis.

Hair that is dull, brittle, or dry, or falls out easily Swollen glands of the neck and cheeks Dry, rough, or spotty skin that may have a sandpaper feel Poor or delayed wound healing or sores Thin appearance with lack of subcutaneous fat Muscle wasting (decreased size and strength) Edema of the lower extremities Weakened hand grasp Depressed mood Abnormal heart rate, heart rhythm, or blood pressure Enlarged liver or spleen Loss of balance and coordination

PHYSICAL SYMPTOMS SUGGESTIVE OF MALNUTRITIONBox 1.5




Pattern Nutrition and MetabolicHigh risk for altered nutrition: intake

exceeds the bodys needsAltered nutrition: intake exceeds the

bodys needsAltered nutrition: eating less than the

body needsEffective breastfeedingIneffective breastfeedingInterrupted breastfeedingIneffective infant feeding patternHigh risk of aspirationSwallowing disorderAltered oral mucosaHigh risk for fl uid volume defi citsFluid volume defi citsExcess fl uid volumeHigh risk for impaired skin integrityImpaired skin integrityImpaired tissue integrityHigh risk for altered body temperatureIneffective thermoregulationHyperthermiaHypothermia

Examples of Other Diagnoses in Which Nutrition Interventions May Be Part of the Care PlanAltered health maintenanceIneffective management of therapeutic

regimenInfectionConstipationDiarrheaBowel incontinenceAltered urinary excretionImpaired physical mobilityFatigueSelf-care defi cit: feedingHousehold alteredAltered tissue perfusionPainChronic painAlterations sensory/perceptualUnilateral oblivionKnowledge defi citsAnxietyBody image disorderSocial isolationIneffective individual copingIneffective family copingDefensive coping

SELECTED NURSING DIAGNOSES WITH NUTRITIONAL SIGNIFICANCEBox 1.6

Nursing InterventionsWhat can you or others do to effectively and effi ciently help the client achieve his or her goals? Interventions may include nutrition therapy and client teaching.

Nutrition Therapy

Throughout this book, the heading Nutrition Therapy is used in place of Diet because, among clients, diet is a four-letter word with negative connotations, such as counting cal-ories, deprivation, sacrifi ce, and misery. A diet is viewed as a short-term punishment to endure until a normal pattern of eating can resume. Clients respond better to terminology that is less emotionally charged. Terms such as eating pattern, food intake, eating style, or the food you eat may be used to keep the lines of communication open.

Nutrition therapy recommendations are usually general suggestions to increase/decrease, limit/avoid, reduce/encourage, or modify/maintain aspects of the diet because exact nutrient requirements are determined on an individual basis. Where more precise amounts of nutrients are specifi ed, consider them as a starting point and monitor the clients response. Box 1.7 highlights formulas for calculating calorie and protein requirements.

Nutrition theory does not always apply to practice. Factors such as the clients prog-nosis, outside support systems, level of intelligence and motivation, willingness to com-ply, emotional health, fi nancial status, religious or ethnic background, and other medical




conditions may cause the optimal diet to be impractical in either the clinical or the home setting. Generalizations do not apply to all individuals at all times. Also, comfort foods (e.g., chicken soup, mashed potatoes, ice cream) are valuable for their emotional benefi ts if not nutritional ones. Honor clients requests for individual comfort foods whenever pos-sible. Box 1.8 suggests ways the nurse can promote an adequate intake.

Client Teaching

Compared with well clients, patients in a clinical setting may be more receptive to nutritional advice, especially if they feel better by doing so or are fearful of a relapse or complications. But hospitalized patients are also prone to confusion about nutrition messages. The patients abil-ity to assimilate new information may be compromised by pain, medication, anxiety, or a dis-tracting setting. Time spent with a dietitian or diet technician learning about a diet may be

A rule-of-thumb method of estimating calorie requirements:

Multiply weight in kg by

30 cal/kg for most healthy adults25 cal/kg for elderly adults2025 cal/kg for obese adults

Example: For an adult weighing 154 pounds:

154 pounds 2.2 kg/pound 70 kg

70 kg 30 cal/kg 2100 cal/day

Estimating protein requirements

Healthy adults need 0.8 g protein/kg

Example: For an adult weighing 154 pounds:

154 pounds 2.2 kg/pound 70 kg

70 kg 0.8 g/kg 56 g protein/day

Box 1.7 CALCULATING ESTIMATED NEEDS

Reassure clients who are apprehensive about eating. Encourage a big breakfast if appetite deteriorates throughout the day. Advocate discontinuation of intravenous therapy as soon as feasible. Replace meals withheld for diagnostic tests. Promote congregate dining if appropriate. Question diet orders that appear inappropriate. Display a positive attitude when serving food or discussing nutrition. Order snacks and nutritional supplements. Request assistance with feeding or meal setup. Get the patient out of bed to eat if possible. Encourage good oral hygiene. Solicit information on food preferences.

WAYS TO PROMOTE AN ADEQUATE INTAKEBox 1.8




brief or interrupted, and the patient may not even know what questions to ask until long after the dietitian is gone. Box 1.9 suggests ways nurses can facilitate client and family teaching.

Monitoring and EvaluationIn the Nursing Process sections of this textbook, monitoring and evaluation are grouped together, even though they are different in practice. In reality, monitoring precedes evalu-ation as a way to stay on top of progress or diffi culties the client is experiencing. Box 1.10 offers general monitoring suggestions. Evaluation assesses whether client outcomes were achieved after the nursing care plan was given time to work. Given the limitations inherent in an abstract nursing care plan, monitoring and evaluation are combined in this textbook.

Ideally, the clients outcomes are achieved on a timely basis, and evaluation statements are client outcomes rewritten from the client will to the client is. In reality, outcomes may be only partially met or not achieved at all; in those instances, it is important to deter-mine why the result was less than ideal. Were the outcomes realistic for this particular client? Were the interventions appropriate and consistently implemented? Evaluation includes deciding whether to continue, change, or abolish the plan.

Consider a male client admitted to the hospital for chronic diarrhea. During the 3 weeks before admission, the client experienced signifi cant weight loss due to malabsorption sec-ondary to diarrhea. Your goal is for the client to maintain his admission weight. Your inter-ventions are to provide small meals of low-residue foods as ordered, to eliminate lactose because of the likelihood of intolerance, to increase protein and calories with appropriate

Listen to the clients concerns and ideas. Encourage family involvement if appropriate. Reinforce the importance of obtaining adequate nutrition. Help the client to select appropriate foods. Counsel the client about drugnutrient interactions. Avoid using the term diet. Emphasize things to do instead of things not to do. Keep the message simple. Review written handouts with the client. Advise the client to avoid foods that are not tolerated.

WAYS TO FACILITATE CLIENT AND FAMILY TEACHINGBox 1.9

Observe intake whenever possible to judge the adequacy. Document appetite and take action when the client does not eat. Order supplements if intake is low or needs are high. Request a nutritional consult. Assess tolerance (i.e., absence of side effects). Monitor weight. Monitor progression of restrictive diets. Clients who are receiving nothing by mouth

(NPO), who are restricted to a clear liquid diet, or who are receiving enteral or paren-teral nutrition are at risk for nutritional problems.

Monitor the clients grasp of the information and motivation to change.

MONITORING SUGGESTIONSBox 1.10




nutrient-dense supplements, and to explain the nutrition therapy recommendations to the client to ease his concerns about eating. You fi nd that the clients intake is poor because of lack of appetite and a fear that eating and drinking will promote diarrhea. You notify the dietitian who counsels the client about low-residue foods, obtains likes and dislikes, and urges the client to think of the supplements as part of the medical treatment, not as a food eaten for taste or pleasure. You document intake and diligently encourage the client to eat and drink everything served. However, the clients weight continues to drop. You attribute this to his reluctance to eat and to the slow resolution of diarrhea related to infl ammation. You determine that the goal is still realistic and appropriate but that the client is not willing or able to consume foods orally. You consult with the physician and dietitian about the clients refusal to eat and the plan changes from an oral diet to tube feeding.

HOW DO YOU RESPOND?Should I save my menus from the hospital to help me plan meals at home? This is not a bad idea if the in-house and discharge food plans are the same, but the menus should serve as a guide, not a gospel. Just because shrimp was never on the menu doesnt mean it is taboo. Likewise, if the client hated the orange juice served every morning, he or she shouldnt feel compelled to continue drinking it. By necessity, hospi-tal menus are more rigid than at-home eating plans.

Can you just tell me what to eat and Ill do it? A black-and-white approach should be used only when absolutely necessary, such as for food allergies or for clients who insist on a rigid plan rather than the freedom to make choices. In most cases, flexible and individ-ualized guidelines and recommendations will promote the greatest chance of compliance. Urge the client not to think of foods as good or bad but rather more healthy and less healthy, except in situations of food allergy or intolerance. In most other cases, foods are negotiable.

CASE STUDYSteven is a 44-year-old male who is 5 ft 11 in tall and weighs 182 pounds. Over the last month, he has lost approximately 10 pounds, which he blames on loss of appetite and fatigue. When he went to his family doctor with flu-like symptoms, a blood test revealed a very high white blood cell count, low platelet count, and low hemoglobin. The doctor told him to proceed to the hospital for admission to rule out acute leukemia. Further laboratory tests are pending. Admitting orders include a regular diet. Steven does not have a signifi-cant medical history. He is married, has three children, and enjoys a successful career.

Calculate and evaluate Stevens weight according to the following standards:

BMI Percent weight change Based on Stevens weight and weight change, is he at nutritional risk? Does Stevens possible diagnosis place him at nutritional risk? What other criteria would help determine his level of risk? Calculate his estimated calorie requirements. Calculate his Recommended Dietary

Allowance (RDA) for protein. If he is treated for leukemia, his protein need may increase to approximately 1.2 g protein/kg.

How much would he then require? The hospitals diet manual says that, on average, a regular diet provides 2400 calories

and 90 g of protein. Is this diet adequate to meet his needs?




S T U D Y Q U E S T I O N S1. Nurses are in an ideal position to

a. Screen patients for risk of malnutrition b. Order therapeutic diets c. Conduct comprehensive nutrition assessments d. Calculate a patients calorie and protein needs

2. How much weight would a 200-pound adult need to lose in a month to be considered significant? a. It depends on the patients BMI. b. More than 5 pounds c. More than 7.5 pounds d. More than 10 pounds

3. Which of the following criteria would most likely be on a nutrition screen in the hospital? a. Prealbumin value b. Weight change c. Serum potassium value d. Cultural food preferences

4. Which of the following statements is accurate regarding physical signs and symptoms of malnutrition? a. Physical signs of malnutrition appear before changes in weight or laboratory

values occur. b. Physical signs of malnutrition are suggestive, not definitive, for malnutrition. c. Physical signs are easily identified as abnormal. d. All races and genders exhibit the same intensity of physical changes in response

to malnutrition.

5. Your patient has a question about the cardiac diet the dietitian reviewed with him yesterday. What is the nurses best response? a. Ask your doctor when you go for your follow-up appointment. b. What is the question? If I cant answer it, I will get the dietitian to come back to

answer it. c. Just do your best. The handout she gave you is simply a list of guidelines, not

rigid instructions. d. If I see the dietitian around, I will tell her you need to see her.

6. Which of the following statements is true regarding albumin? a. Albumin is a reliable and sensitive indicator of protein status. b. An increase in serum albumin accurately reflects the adequacy of nutrition therapy. c. An increase in albumin levels means nutrition therapy is adequate. d. Low albumin is associated with morbidity, mortality, and risk of malnutrition

because it reflects severity of illness.

Nutrition is an integral part of nursing care. Like air, food is a basic human need. Nutrition screening is used to identify patients or clients who may be at risk for

malnutrition. Screening tools are simple, quick, easy to use, and rely on available data. The Joint Commission stipulates that nutrition screens be performed within 24 hours

of admission to a health-care facility, but facilities are free to decide what criteria to include on a screen, what fi ndings indicate risk, and who is to conduct the screen.

K E Y C O N C E P T S




Screens are often the responsibility of staff nurses because they can be completed during a history and physical examination upon admission.

Patients who are identifi ed to be a low or no nutritional risk are rescreened within a specifi ed period of time to determine whether their nutritional risk status has changed.

Patients who are found to be a moderate to high nutritional risk at screening receive a comprehensive nutritional assessment by the dietitian that includes the steps of assessment, diagnosis, intervention, and monitoring and evaluation.

Dietitians use information from the nursing history and physical examination to begin the assessment process. They may also obtain a nutritional history from the patient, cal-culate estimated protein and calorie needs, assess the adequacy and appropriateness of the diet order, and identify the patients diagnostic code for malnutrition, if appropriate.

Nurses can integrate nutrition into the nursing care process to develop care plans that address the individuals needs. Nurses are not expected to be dietitians but rather use nutrition to provide quality nursing care.

Albumin and prealbumin are not valid criteria for assessing protein status because they become depleted from infl ammation and physiologic stress.

Accurate height and weight are essential for assessing risk and monitoring progress. They are used to determine BMI and percentage of weight loss. Signifi cant unintentional weight loss is defi ned according to the length of time over which the loss occurred.

Dietary data can help determine whether a nutrition problem is caused by intake or by illness or its treatments. The term diet inspires negative feelings in most people. Replace it with eating pattern, eating style, or foods you normally eat to avoid negative connotations.

People with gastrointestinal symptoms, such as nausea, vomiting, diarrhea, and anorexia, that last more than 2 weeks are at risk for malnutrition.

Physical signs and symptoms of malnutrition are nonspecifi c, subjective, and develop slowly and should be considered suggestive, not diagnostic, of malnutrition.

Medicalpsychosocial history can reveal factors that infl uence intake, nutritional requirements, or nutrition counseling needs.

Medications and nutritional supplements should be evaluated for their potential impact on nutrient intake, absorption, utilization, or excretion.

Nursing diagnoses relate directly to nutrition when the pattern of nutrition or metabo-lism is altered. Many other nursing diagnoses, such as constipation, impaired skin integ-rity, knowledge defi cits, and infection, may include nutrition in some aspect of the plan.

A nutrition priority for all clients is to obtain adequate calories and nutrients based on individual needs.

Short-term nutrition goals are to attain or maintain adequate weight and nutritional status and (as appropriate) to avoid nutrition-related symptoms and complications of illness. Client-centered outcomes should be measurable, attainable, and specifi c.

Intake recommendations are not always appropriate for all persons; what is recom-mended in theory may not work for an individual. Clients may revert to comfort foods during periods of illness or stress.

Nurses can reinforce nutrition counseling provided by the dietitian and initiate counsel-ing for clients with low or mild risk.

Use preprinted lists of dos and donts only if absolutely necessary, such as in the case of food allergies. For most people, actual food choices should be considered in view of how much and how often they are eaten rather than as foods that must or must not be consumed.




C h e c k Yo u r K n o w l e d g e A n s w e r K e y 1. FALSE The nurse is in an ideal position to provide nutrition information to patients and

their families since he or she is the one with the greatest client contact.

2. TRUE Nutritional screening uses a small number of factors to identify patients or clients with malnutrition or at risk of malnutrition.

3. FALSE Hospitals and health-care facilities are free to decide what criteria they will use to identify risk for malnutrition and what defines risk. For instance, one hospital may use acute pancreatitis as a high-risk diagnosis, whereas another may not.

4. FALSE Changes in weight may be slow to occur. Weight changes are more reflective of chronic, not acute, changes in nutritional status.

5. TRUE A person can be malnourished without being underweight. Weight does not provide qualitative information about body composition.

6. FALSE Low serum albumin levels may be caused by problems other than protein mal-nutrition, such as injury, infection, overhydration, and liver disease.

7. TRUE Weight loss is judged as significant if there is a 5% loss over the course of 1 month.

8. TRUE People who take five or more prescription drugs, over-the-counter drugs, or dietary supplements are at increased risk for developing drug-induced nutrient deficiencies.

9. TRUE Determining what the patient normally eats can help diagnose the role of intake in the nutritional problem as primary, secondary, or insignificant.

10. TRUE Physical signs and symptoms of malnutrition develop only after other signs of malnutrition, such as laboratory values and weight changes, are observed.

Student Resources on

For additional learning materials, activate the code in the front of this book at http://thePoint.lww.com/activate

For more on the nutrition care process used by dietitians, go to http://www.eatright.org/HealthProfessionals/content.aspx?id=5902

Find tools to assess dietary intake in well people at http://fnic.nal.usda.gov/dietary-guidance/dietary-assessment

W e b s i t e s

Academy of Nutrition and Dietetics. (2012). Nutrition Care Manual. Available at http://www.nutritioncaremanual.org. Accessed on 8/15/12.

Banh, L. (2006). Serum proteins as markers of nutrition: What are we treating? Practical Gastroenterology, 30, 4664.

Fessler, T. (2008). Malnutrition: A serious concern for hospitalized patients. Todays Dietitian, 10, 4448.

White, J., Guenter, P., Jensen, G., Malone, A., Schofield, M., Academy Malnutrition Work Group, . . . ASPEN Board of Directors. (2012). Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics recommended for the identification and documentation of adults malnutrition (undernutrition). Journal of the Academy of Nutrition and Dietetics, 112, 730738.

R e f e r e n c e s



2 Carbohydrates

18

C H E C K Y O U R K N O W L E D G E

TRUE FALSE

1 Starch is made from glucose molecules.

2 Sugar is higher in calories than starch.

3 The sugar in fruit is better for you than the sugar in candy.

4 Most commonly consumed American foods provide adequate fi ber to enable people to meet the recommended intake.

5 Enriched wheat bread is nutritionally equivalent to whole wheat bread.

6 Soft drinks and energy/sports drinks contribute more added sugars to the typical American diet than any other food or beverage.

7 Bread is just as likely as candy to cause cavities.

8 The sugar content on food labels refers only to added sugars, not those naturally present in the food.

9 The safety of nonnutritive sweeteners is questionable.

10 Sugar causes hyperactivity in kids.

U p o n c o m p l e t i o n o f t h i s c h a p t e r, y o u w i l l b e a b l e t o

1 Classify the type(s) of carbohydrate found in various foods.2 Describe the functions of carbohydrates.3 Modify a menu to ensure that the adequate intake for fi ber is provided.4 Calculate the calorie content of a food that contains only carbohydrates.5 Debate the usefulness of using glycemic load to make food choices.6 Suggest ways to limit sugar intake.7 Discuss the benefi ts and disadvantages of using sugar alternatives.

L E A R N I N G O B J E C T I V E S



C H A P T E R 2 Carbohydrates 19

CARBOHYDRATES

Sugar and starch come to mind when people hear the word carbs, but carbohydrates are so much more than just table sugar and bread. Foods containing carbohydrates can be empty calories, nutritional powerhouses, or something in between. Globally, carbohydrates provide the majority of calories in almost all human diets.

This chapter describes what carbohydrates are, where they are found in the diet, and how they are handled in the body. Recommendations regarding intake and the role of car-bohydrates in health are presented.

Carbohydrate Classifi cationsCarbohydrates (CHO) are comprised of the elements carbon, hydrogen, and oxygen arranged into basic sugar molecules. They are classifi ed as either simple sugars or complex carbohydrates (Fig. 2.1).

Simple Sugars

Simple sugars contain only one (mono-) or two (di-) sugar (saccharide) molecules; they vary in sweetness and sources (Table 2.1). Monosaccharides, such as glucose, fructose, and galactose, are absorbed as is without undergoing digestion; disaccharides, such as sucrose (table sugar), maltose, and lactose, must be split into their component monosac-charides before they can be absorbed.

Glucose, also known as dextrose, is the simple sugar of greatest distinction: it circulates through the blood to provide energy for body cells; it is a component of all disaccharides and is virtually the sole constituent of complex carbohydrates; and it is the sugar to which the body converts all other digestible carbohydrates.

Complex Carbohydrates

Complex carbohydrates, also known as polysaccharides, are composed of hundreds to thousands of glucose molecules linked together. Despite being made of sugar, polysaccha-rides do not taste sweet because their molecules are too large to fi t on the tongues taste bud receptors that sense sweetness. Starch, glycogen, and fi ber are types of polysaccharides.

Starch. Through the process of photosynthesis, plants synthesize glucose, which they use for energy. Glucose not used by the plant for immediate energy is stored in the form of starch in seeds, roots, or stems. Grains, such as wheat, rice, corn, barley, millet, sorghum,

Carbohydrates

Simple sugars

Monosaccharides

glucose fructose galactose

Disaccharides

sucrose maltose lactose

Polysaccharides

starch glycogen fiber

Complex carbohydrates

F I G U R E 2 . 1 Carbohydrate classifications.

Carbohydrates (CHO): a class of energy- yielding nutrients that contain only carbon, hydrogen, and oxygen, hence the common abbreviation of CHO.Simple Sugars: a classification of carbohy-drates that includes monosaccharides and disaccharides; commonly referred to as sugars.Complex Carbohydrates: a group name for starch, glycogen, and fiber; composed of long chains of glucose molecules.Monosaccharide: single (mono) molecules of sugar (saccharide); the most common mono-saccharides in foods are hexoses that contain six carbon atoms.Disaccharide: double sugar composed of two (di) monosaccharides (e.g., sucrose, maltose, lactose).Polysaccharides: carbohydrates consisting of many (poly) sugar molecules.Starch: the storage form of glucose in plants.




Relative Sweetness Sources

MonosaccharidesGlucose (also known as

dextrose) 70 Fruit, vegetables, honey, corn syrup,

cornstarchFructose (also known as

fruit sugar)170 Fruit, honey, some vegetables

Galactose 60 Does not occur in appreciable amounts in foods; significant only as it combines with glucose to form lactose

DisaccharidesSucrose (composed of

glucose and fructose)100 Fruit, vegetables

Extracted from sugarcane and sugar beets into white, brown, confectioners, and turbinado sugars

Maltose (composed of two glucose molecules)

50 Not found naturally in foods; added to some foods for flavoring (e.g., malted milk shakes) and to beer for coloring

Is an intermediate in starch digestionLactose (composed of

glucose and galactose) 40 Milk sugar; used as an additive in

many foods and drugs

Table 2.1 Simple Sugars

oats, and rye, are the worlds major food crops and the foundation of all diets. Other sources of starch include potatoes, legumes, and other starchy vegetables.

Glycogen. Glycogen is the animal (including human) version of starch; it is stored car-bohydrate available for energy as needed. Humans have a limited supply of glycogen stored in the liver and muscles. Liver glycogen breaks down and releases glucose into the blood-stream between meals to maintain normal blood glucose levels and provide fuel for tissues. Muscles do not share their supply of glycogen but use it for their own energy needs. There is virtually no dietary source of glycogen because any glycogen stored in animal tissue is quickly converted to lactic acid at the time of slaughter. Miniscule amounts of glycogen are found in shellfish, such as scallops and oysters, which is why they taste slightly sweet com-pared to other fish.

Fiber. Although there is no universally accepted definition of fiber, it is generally consid-ered a group name for polysaccharides that cannot be digested by human enzymes. These polysaccharides include cellulose, pectin, gums, hemicellulose, -glucans, inu-lin, oligosaccharides, fructans, lignin, and some resistant starch. Often referred to as roughage, fiber is found only in plants as a component of plant cell walls or intercel-lular structure.

Historically, fi bers have been categorized as insoluble or soluble for the purpose of assigning specifi c functions to each category. For instance, soluble fi bers are credited with slowing gastric emptying time to promote a feeling of fullness, delaying and blunting the rise in postprandial serum glucose, and lowering serum cholesterol, whereas insoluble fi ber is credited with increasing stool size to promote laxation. However, there is inconsistent evidence at best that each type has different and specifi c functions (American Dietetic

Glycogen: storage form of glucose in animals and humans.

Insoluble Fiber: nondigestible carbohydrates that do not dissolve in water.Soluble Fiber: nondigestible carbohy-drates that dissolve to a gummy, viscous texture.




Association, 2008). In reality, although sources of fi ber may be considered either soluble or insoluble, almost all sources of fi ber provide a blend of different fi bers.

The National Academy of Sciences recommends that the terms insoluble and solu-ble be phased out in favor of ascribing specifi c physiologic benefi ts to a particular fi ber. Dietary fi ber refers to intact and naturally occurring fi ber found in plants; functional fi berrefers to fi ber that has been isolated or extracted from plants that has benefi cial physiologic effects in the body. The sum of dietary and functional fi ber equals total fi ber. The rationale for discontinuing soluble and insoluble fi ber is that the amounts of soluble and insoluble fi bers measured in a mixed diet are dependent on methods of analysis that are not able to exactly replicate human digestion.

It is commonly assumed that fi ber does not provide any calories because it is not truly digested by human enzymes and may actually trap macronutrients eaten at the same time and prevent them from being absorbed. Yet most fi bers, particularly soluble fi bers, are fermented by bacteria in the colon to produce carbon dioxide, methane, hydrogen, and short-chain fatty acids, which serve as a source of energy (calories) for the mucosal lining of the colon. Although the exact energy value available to humans from the blend of fi bers in food is unknown, current data indicate the value is between 1.5 and 2.5 cal/g (Institute of Medicine, 2005).

Sources of CarbohydratesSources of carbohydrates include natural sugars in fruit and milk; starch in grains, veg-etables, legumes, and nuts; and added sugars in foods with empty calories. Servings of commonly consumed grains, fruit, and vegetables contain only 1 to 3 g of dietary fi ber; legumes are rich in fi ber (Table 2.2). Figure 2.2 shows the average carbohydrate and fi ber content of each MyPlate food group.

Grains

This group is synonymous with carbs and consists of grains (e.g., wheat, barley, oats, rye, corn, and rice) and products made with fl ours from grains (e.g., bread, crackers, pasta, and tortillas).

Grains are classifi ed as whole or refi ned (Box 2.1).Whole grains consist of the entire kernel of a grain (Fig. 2.3).They may be eaten whole as a complete food (e.g., oat-meal, brown rice, or popcorn) or milled into fl our to be used as an ingredient in bread, cereal, and baked goods. Even when whole grains are ground, cracked, or fl aked, they must have the same proportion of the original three parts:

The bran, or tough outer coating, which provides antioxidants, iron, zinc, copper, mag-nesium, B vitamins, fiber, and phytochemicals.

The endosperm, the largest portion of the kernel, which supplies starch, protein, and small amounts of vitamins and minerals.

The germ (embryo), the smallest portion of the kernel that contains B vitamins, vitamin E, antioxidants, phytochemicals, and unsaturated fat. Its unsaturated fat content makes whole wheat flour more susceptible to rancidity than refined flour.

Bran cereals and wheat germ are not whole grains because they come from only one part of the whole.

Refi ned grains have most of the bran and germ removed. They are rich in starch but lack the fi ber, B vitamins, vitamin E, trace minerals, unsaturated fat, and most of the phyto-chemicals found in whole grains (International Food Information Council, 2009). The process of enrichment restores some B vitamins (thiamin, ribofl avin, and niacin) and iron to levels

Dietary Fiber: carbo-hydrates and lignin that are natural and intact components of plants that cannot be digested by human enzymes.Functional Fiber: as proposed by the Food and Nutrition Board, functional fiber consists of extracted or isolated nondigestible carbohy-drates that have benefi-cial physiologic effects in humans.Total Fiber: total fiber dietary fiber functional fiber.

Added Sugars: caloric sugars and syrups added to foods during processing preparation or consumed separately; do not include sugars naturally present in foods, such as fructose in fruit and lactose in milk.Whole Grains and Whole Grain Flours: contain the entire grain, or seed, which includes the endosperm, bran, and germ.Phytochemicals: bioactive, nonnutrient plant compounds asso-ciated with a reduced risk of chronic diseases.Refined Grains and Refined Flours: consist of only the endosperm (middle part) of the grain and therefore do not contain the bran and germ portions.Enrichment: adding back certain nutrients (to specific levels) that were lost during processing.




Table 2.2 Fiber Content of Selected Foods

Food Total Fiber (g)

Breads (1 slice)Rye 1.9White 0.7Whole wheat 1.9

Cereals ( cup)All-Bran 8.8Cream of Wheat 0.6Cornflakes 0.3Oatmeal 2.0Puffed rice 0.1

Fruit (1 medium unless otherwise specified)Apple with skin 3.3Banana 3.0Orange 3.0Peach 1.5Strawberries ( cup) 1.6Tangerine 1.5Watermelon ( cup) 0.3

Legumes ( cup cooked)Baked, vegetarian 5.2Great northern 6.2Lentils 7.8Lima 5.4Navy 9.5White 6.3

Nuts (1 oz)Almonds (24 nuts) 3.3Cashews (18 nuts) 0.9Pistachios (47 nuts) 2.8Walnuts (14 halves) 1.9

Vegetables ( cup cooked)Asparagus 1.4Broccoli 2.5Brussels sprouts 2.0Cabbage 1.5Collards 2.4Mustard greens 1.4Sweet potato 3.0Tomatoes 2.4

Source: U.S. Department of Agriculture National Nutrient Database for Standard Reference, Release 24. (n.d.). Available at https://www.ars.usda.gov/SP2UserFiles/Place/12354500/Data/SR24/nutrlist/sr24a291.pdf. Accessed 8/28/2012.

found prior to processing. Other substances that are lost, such as other vitamins, other miner-als, fi ber, and phytochemicals, are not replaced by enrichment. Enriched grains are also required to be fortifi ed with folic acid, a mandate designed to reduce the risk of neural tube defects. Examples of refi ned grains include white fl our, white bread, white rice, and refi ned cornmeal.

Whether whole or refi ned, a serving of grain is estimated to provide 15 g of carbo-hydrates. Fiber content can range from 0 g in refi ned grains to 10 g or more per serving

Fortified: adding nutrients that are not naturally present in the food or were present in insignificant amounts.




Whole Grains Refi ned Grains

Whole wheat grain, including varieties of spelt, emmer, faro, einkorn, bulgur, cracked wheat, and wheat berries

Cream of Wheat, puffed wheat, refi ned ready-to-eat wheat cereals

Products made with whole wheat fl our, such as 100% whole wheat bread, whole wheat pasta, shredded wheat, Wheaties, whole wheat tortillas, whole wheat crackers

Products made with enriched white or wheat fl our as found in white or wheat bread, white pasta, fl our tortillas, refi ned crackers

Whole oats, oatmeal, Cheerios Oat fl our

Brown rice White rice, Rice Krispies, cream of rice, puffed rice

Corn, popcorn Cornstarch, grits, hominy, cornfl akesWhole-grain barley, whole rye, teff, triti-

cale, millet, amaranth*, buckwheat*, sorghum*, quinoa*, wild rice*

Pearled barley

*Considered whole grains but are technically not cereals but rather pseudocereals.

SOURCES OF WHOLE AND REFINED GRAINSBox 2.1

of high-fi ber cereals. Some items in this group, such as sweetened ready-to-eat cereals, muffi ns, and pancakes, have added sugar.

Vegetables

Starch and some sugars provide the majority of calories in vegetables, but the content varies widely among individual vegetables. A cup serving of the following starchy vegetables provides approximately 15 g carbohydrates:

CornLegumes (e.g., pinto beans, black beans, garbanzo beans)LentilsPeasPotatoes, sweet potatoes, yamsWinter squash (e.g., acorn, butternut)

F I G U R E 2 . 2 Carbohydrate content of MyPlate groups. (Source: U.S. Department of Agriculture, Center for Nutrition Policy and Promotion. [2011]. Available at www.choosemyplate.gov)

1 2/

15g carbohydrate per 1ounce equivalent serving,One 1 ounce serving is about: 1 slice bread 1 cup breakfast cereal cup cooked rice, cereal, pastaFiber content varies

5g carbohydrate in cupwatery vegetables, 15gcarbohydrate in cupstarchy vegetables, mostvegetables have 1-3g fiberin cup

15g carbohydrate, 1-3g fiberin: 1 medium piece of fruit cup canned fruit cup fruit juice

12g carbohydrate, 0g fiber in: 1 cup milk, buttermilk, artificially sweetened yogurt, plain yogurtHigher carbohydrate content in sweetened milks and yogurtNo carbohydrate in hard cheeses

Dry peas and beans: 15g carbohydrate, 5-8g fiber in cupNuts: 4-8g carbohydrate, 1-3g fiber in 1-2 oz.No other items in this group naturally provide carbohydrate

GRAINSMake half your grains whole

VEGETABLESVary your veggies

FRUITSFocus on fruits

DAIRYGet your calcium-rich foods

PROTEIN FOODSGo lean with protein

1 2/

1 2/

1 2/1 2/3 4/

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In comparison, watery vegetables provide 5 g carbohydrate or less per cup serving:

AsparagusBean sproutsBroccoliCarrotsGreen beans, wax beansOkraTomatoes

The average fi ber content of vegetables is 2 to 3 g per serving.

Fruits

Generally, almost all of the calories in fruit come from the natural sugars fructose and glucose. (The exceptions to this are avocado, olives, and coconut, which get the ma-jority of their calories from fat.) A serving of fruit, defi ned as cup of juice, 1 piece of fresh fruit, cup of canned fruit, or cup of dried fruit, provides 15 g carbohy-

drate and approximately 2 g fi ber. Because fi ber is located in the skin of fruits, fresh whole fruits provide more fi ber than do fresh peeled fruits, canned fruits, or fruit juices. The effect of processing on fi ber content is demonstrated in the examples on the left.

Provides:protein, starch,small amountsof vitamins, and trace minerals

Provides:B vitamins,some protein,healthy fat, vitamin E,minerals, antioxidants,and phytochemicals

EndospermStorage sitefor starch; mainsource of flour

BranOuter layer that protects rest of kernel from sunlight, pests, water, and diseaseProvides:fiber, antioxidants, B vitamin, iron, zinc,copper, magnesium, and phytochemicalsfrom sunlight, pests, water, and disease

Refined grains: made only from endosperm are enriched with thiamin, riboflavin, niacin, and iron lost through processing are fortified with folic acid are inferior to whole grains in vitamin B , protein, pantothenic acid, vitamin E, fiber, phytochemicals

GermEmbryo thatwill sprout intoanother plantif fertilized

6

F I G U R E 2 . 3 Whole wheat. The components of the whole wheat kernel are the bran, the germ, and the endosperm.

Fiber (g/serving)

Unpeeled fresh apple (1) 3.0Peeled fresh apple (1) 1.9Applesauce ( cup) 1.5Apple juice ( cup) Negligible




Dairy

Although milk is considered a protein, more of milks calories come from carbohydrate than from protein. One cup of milk, regardless of the fat content, provides 12 g of carbohy-

drate in the form of lactose. Flavored milk and yogurt have added sugars, as do ice cream, ice milk, and frozen yogurt. With the exception of cottage cheese, which has about 6 g of carbohydrate per cup, cheese is virtually lactose free because lactose is converted to lactic acid during production. The carbohydrate content, including both natural and added sugars, of various dairy foods is listed in the box on the left.

Empty Calories

Empty carbohydrate calories are calories that come from added sugars and syrups; these ingredients provide calories with few or no nutrients. Sometimes, 100% of the calories in a food are from added sugar, such as in pancake syrup, sweetened soft drinks, and hard

candies. In other products, added sug-ars account for only some of the calo-ries. For instance, in the chocolate milk listed above, added sugars provide 14 g (56 empty calories) of the 26 g total carbohydratethe difference between the total carbohydrate in chocolate milk compared to the total carbohy-drate (the natural sugar lactose) in plain milk. Only the calories of the added sugar are considered empty.

How the Body Handles CarbohydratesDigestion

Cooked starch begins to undergo digestion in the mouth by the action of salivary amylase, but the overall effect is small because food is not held in the mouth very long (Fig. 2.4). The stomach churns and mixes its contents, but its acid medium halts any residual effect of the swallowed amylase. Most carbohydrate digestion occurs in the small intestine, where pancreatic amylase reduces complex carbohydrates into shorter chains and disaccharides.

Disaccharidase enzymes (maltase, sucrase, and lactase) on the surface of the cells of the small intestine split maltose, sucrose, and lactose, respectively, into monosaccharides. Monosaccharides are the only form of carbohydrates the body is able to absorb intact and the form all other digestible carbohydrates must be reduced to before they can be absorbed. Normally, 95% of starch is digested usually within 1 to 4 hours after eating.

Absorption

Glucose, fructose, and galactose are absorbed through intestinal mucosa cells and travel to the liver via the portal vein. Small amounts of starch that have not been fully digested pass into the colon with fi ber and are excreted in the stools. Fibers may impair the absorption of some mineralsnamely, calcium, zinc, and ironby binding with them in the small intestine.

Carbohydrate (g)

Milk, 8 oz 12Chocolate milk, 8 oz 26Plain yogurt, 8 oz 15Strawberry yogurt, 8 oz 48.5Regular vanilla ice

cream, cup15.6

Swiss cheese, 1 oz 1

Q U I C K B I T E

Sugar content of selected extras

Sugar (g)White sugar, 1 tsp 4.0Brown sugar, 1 tsp 4.5Jelly, 1 tsp 4.5Gelatin, cup 19.0Cola drink, 12 oz 40.0



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Nutrition Essentials for Nursing Practice-2014-CD

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